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General NPI Number Information
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NPI Number | 1689566184
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Entity Type | Individual
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Provider Name | LATASHA TENE MALLORY
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Gender | Female
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Dates
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Enumeration Date | 07/18/2025
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Last Update Date | 07/18/2025
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Provider Practice Location Address
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Address Line | 303 E WACKER DR STE 1127
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City | CHICAGO
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State | IL
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Zip | 60601-5215
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Country | US
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Telephone | 312-736-1776
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Fax |
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Provider Business Mailing Address
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Address Line | 605 S 9TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-1530
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Country | US
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Telephone | 708-227-5159
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 180005020
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License Number State | IL
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